Targeted treatment of mature t-cell lymphoma

ABSTRACT

A method and medicament comprising 4,4,4-trifluoro-N-[(IS)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide or a pharmaceutically acceptable salt or hydrate thereof for treating aggressive peripheral T-cell lymphoma is provided.

Mature T-cell lymphoma (more frequently called peripheral T-cell lymphoma; PTCL) is a group of rare and usually aggressive non-Hodgkin lymphomas that develop from mature T lymphocytes. Cancerous T lymphocytes travel to various parts of the body through the lymphatic system, although not confined to the lymphatic system, and form a solid tumor. PTCL tumors are sub-classified into various subtypes primarily based on their distinct clinical differences. The three most common subtypes of PTCL are peripheral T-cell lymphoma not otherwise specified (PTCL-NOS), anaplastic large-cell lymphoma (ALCL), and angioimmunoblastic T-cell lymphoma (AITL). Each of these three subtypes is an aggressive cancer.

Treatment regimens generally comprise combination chemotherapy, such as CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone), EPOCH (etoposide, vincristine, doxorubicin, cyclophosphamide, prednisone), or other multi-drug regimen. More recently approved treatments include belinostat, a histone deacetylase inhibitor for treatment of patients with relapsed or refractory PTCL; pralatrexate for treatment of patients with relapsed or refractory PTCL; and romidepsin for the treatment of PTCL in patients who have received at least one prior therapy. Most patients with PTCL will relapse.

Notch signaling is an evolutionary conserved pathway that plays an integral role in development and tissue homeostasis in mammals. The Notch receptors and ligands contain single-pass transmembrane domains, are expressed on the cell surface and, for that reason, Notch signaling is particularly important in mediating communication between adjacent cells expressing the receptors and ligands. There are four known Notch receptors found in rodents and humans, termed Notch 1 to Notch 4. The Notch receptors are heterodimeric proteins composed of extracellular and intracellular domains that are initially synthesized as a single polypeptide. Receptor-ligand interaction triggers a series of proteolytic cleavages of the Notch receptor polypeptide in which y-secretase activity is involved. y-Secretase activity cleaves Notch intracellular domain from the cell surface which translocates to the nucleus to form a transcription factor complex. Notch intracellular domain (NICD) is the active form of the protein. Various Notch signaling functions include proliferation, differentiation, apoptosis, angiogenesis, migration and self-renewal. These diverse roles of Notch signaling during the development and maintenance of normal tissues are aberrantly activated in different forms of cancer. The oncogenic functions of Notch signaling include the inhibition of apoptosis and the promotion of cell proliferation.

Recently, a specific Notch pathway signaling inhibitory compound having activity against various tumor types has been disclosed in WO 2013/016081.

There is a need for therapeutic agents that exhibit activity (efficacy) in the treatment of PTCL, particularly aggressive forms of PTCL. There is also a need for an alternative therapeutic agent to those combinations and individual therapeutic agents currently used to treat PTCL. The Notch inhibitor 4,4,4-trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide, or a pharmaceutically acceptable salt or hydrate thereof, is an alternative therapeutic agent and evidences surprising and unexpected therapeutic activity against PTCL, particularly aggressive forms of PTCL.

One aspect of the invention provides a method of treating a patient suffering from aggressive PTCL comprising administering to a PTCL-NOS, ALCL, or AITL patient in need of treatment an effective amount of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide, or a pharmaceutically acceptable salt or hydrate thereof.

Another aspect of the invention provides a method of treating a patient suffering from aggressive PTCL comprising administering to a PTCL-NOS, ALCL, or AITL patient in need of treatment 25 to 75 mg/dose of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide or a pharmaceutically acceptable salt or hydrate thereof.

A further aspect of the invention provides a method of treating a patient suffering from aggressive PTCL comprising administering to a PTCL-NOS, ALCL, or AITL patient in need of treatment 25 to 75 mg/dose three times per week over a seven day week of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide or a pharmaceutically acceptable salt or hydrate thereof.

Another aspect of the invention provides a compound or a pharmaceutically acceptable salt or hydrate thereof for use in the treatment of aggressive PTCL which is PTCL-NOS, ALCL, or AITL, wherein the compound is 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide or a pharmaceutically acceptable salt or hydrate thereof.

A further aspect of the invention provides a compound or a pharmaceutically acceptable salt or hydrate thereof for use in the treatment of aggressive PTCL which is PTCL-NOS, ALCL, or AITL, wherein the compound is 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide or a pharmaceutically acceptable salt or hydrate thereof, administered at 25 to 75 mg/dose.

Another aspect of the invention provides a compound or a pharmaceutically acceptable salt or hydrate thereof for use in the treatment of aggressive PTCL which is PTCL-NOS, ALCL, or AITL, wherein the compound is 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide or a pharmaceutically acceptable salt or hydrate thereof administered at 25 to 75 mg/dose three times per week over a seven day week.

A further aspect of the invention provides the use of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide, or a pharmaceutically acceptable salt or hydrate thereof, for preparation of a medicament for treatment of aggressive PTCL which is PTCL-NOS, ALCL, or AITL.

Another aspect of the present invention provides the use of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide, or a pharmaceutically acceptable salt or hydrate thereof, for preparation of a medicament for treatment of aggressive PTCL which is PTCL-NOS, ALCL, or AITL wherein said medicament is to be administered at a dose of 25 to 75 mg of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide, or a pharmaceutically acceptable salt or hydrate thereof.

A further aspect of the present invention provides the use of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide, or a pharmaceutically acceptable salt or hydrate thereof, for preparation of a medicament for treatment of aggressive PTCL which is PTCL-NOS, ALCL, or AITL wherein said medicament is to be administered three times per week over a seven day week at a dose of 25 to 75 mg of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide, or a pharmaceutically acceptable salt or hydrate thereof.

The compound 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide is taught to be a Notch inhibitor in WO 2013/016081. The name identifies a compound having the following structure:

Compound 1 is named: 4,4,4-trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide (IUPAC); and may also be named: N-[(1 S)-2-[[(7S)-6,7-dihydro-5-(2-hydroxyethyl)-6-oxo-5H-pyrido[3,2-a][3]benzazepin-7-yl]amino]-1-methyl-2-oxoethyl]-4,4,4-trifluorobutanamide (CAS); and other names to unambiguously identify Compound 1.

It will be understood Compound 1 is depicted as a single stereoisomer. There are two chiral centers giving rise to four diastereomers. As used herein, references to Compound 1 are meant to also include racemic mixtures including Compound 1. Herein, the Cahn-Ingold-Prelog designations of (R)- and (S)- are used to refer to specific isomers. Specific stereoisomers can be prepared by stereospecific synthesis using enantiomerically pure or enriched starting materials. The specific stereoisomers of either starting materials, intermediates, or racemic mixtures including Compound 1 can be resolved by techniques well known in the art, such as those found in Stereochemistry of Organic Compounds. E. I.

Eliel and S. H. Wilen (Wiley 1994) and Enantiomers. Racemates. and Resolutions, J., Jacques, A Collet, and S. H. Wilen (Wiley 1991), including chromatography on chiral stationary phases, enzymatic resolutions, or fractional crystallization or chromatography of diastereomers formed for that purpose, such as diastereomeric salts. While all mixtures containing the compound of the present invention are contemplated within the present invention, the preferred embodiment is Compound 1.

It has also been found that Compound 1 exists as atropisomers, or specific conformers. In aqueous solutions, 8-9% of atropisomer 2 (minor atropisomer) is detected by ¹H NMR and LC-MS in equilibrium with atropisomer 1 (major atropisomer) at ambient temperature after 24 hours. In organic solvents, at ambient temperature after 24 hours, approximately 1-2% of atropisomer 2 is detected by ¹H NMR and LC-MS in equilibrium with atropisomer 1. Although detectable by ¹H NMR and LC-MS analysis, atropisomer 2 is not isolable.

“Effective amount” means the dosage of Compound 1, or pharmaceutically acceptable salt or hydrate thereof, or pharmaceutical composition containing the compound, or pharmaceutically acceptable salt or hydrate thereof, necessary to inhibit Notch signaling in an aggressive PTCL patient, and either destroy the target cancer cells or slow or arrest the progression of the cancer in a patient. Dosages of Compound 1 or a pharmaceutically acceptable salt or hydrate thereof in an adult are in the range of 25 to 75 mg/dose. In a pediatric patient, dosages may be lower and are anticipated to be based on surface area. The exact dosage required to treat a patient and the length of treatment time will be determined by a physician in view of the age, stage and severity of the disease as well as the specific needs and response of the individual patient.

The administration regimen may be adjusted to provide a more optimal therapeutic benefit to a patient and to manage or ameliorate observed gastrointestinal toxicities such as diarrhea, nausea, vomiting, mucoid enteropathy (hypersecretion and accumulation of mucus in the gastrointestinal tract), and/or colitis, or symptoms related to tumornecrosis. Preferred administration is every other day over a five day period followed by two days without administration (T.I.W.) during a 28-day cycle. An alternative preferred administration regimen is to administer to a patient in need of treatment, a loading dose of: a) at least one dose and up to 12 doses; orb) at least one dose and up to 6 doses; or c) at least one dose and up to 3 doses, at 75-150 mg/dose administered twice or three times per week during a 28 day cycle; followed by a maintenance dose of 50 mg/dose administered three times per week; and optionally administering, during administration of the loading dose, 1-50 mg/day of a corticosteroid. At least one loading dose is administered and as many as 12 loading doses over one 28 day cycle are administered. Preferably, 1 to 6 loading doses are administered over 14 days of a 28 day cycle. Also preferably, at least one loading dose and up to 3 loading doses are administered over 7 days of a 28 day cycle. It will be appreciated the number of loading doses is dependent on whether the administration regimen is twice per week or three times per week. A maintenance or second dose of 50 mg per dose is administered TIW following the loading dose or doses. Preferably, the maintenance dose is administered over any remaining days of a first 28 day cycle to one or more additional 28 day cycles. The optional, administration (pre-, concomitant, or post-administration of Compound 1) of a corticosteroid, such as hydrocortisone, hydrocortisone acetate, cortisone acetate, tixocortol pivalate, prednisolone, methylprednisolone, prednisone, and dexamethasone is on an as needed basis to manage or ameliorate gastrointestinal toxicities including diarrhea, nausea, vomiting, mucoid enteropathy and/or colitis. Any or all of the dosage, administration regimen and cycle, may be modified at the discretion of a physician due to tumor necrosis or other factors.

The term “aggressive PTCL” and “aggressive peripheral T-cell lymphoma” means a solid tumor selected from peripheral T-cell lymphoma not otherwise specified (PTCL-NOS), anaplastic large-cell lymphoma (ALCL), and angioimmunoblastic T-cell lymphoma (AITL).

The terms “treatment,” “treat,” and “treating,” are meant to include the full spectrum of intervention for the cancer from which the patient is suffering, such as administration of the active compound to alleviate, slow, or reverse one or more of the symptoms and to delay progression of the cancer even if the cancer is not actually eliminated. The patient to be treated is a mammal, in particular a human.

The compound of the present invention is preferably formulated as a pharmaceutical composition using a pharmaceutically acceptable carrier and administered by a variety of routes. Preferably, such compositions are for oral administration. Such pharmaceutical compositions and processes for preparing them are well known in the art. See, e.g., REMINGTON: THE SCIENCE AND PRACTICE OF PHARMACY, L. V. Allen, Editor, 22^(nd) Edition, Pharmaceutical Press, 2012). In a particular embodiment, the pharmaceutical composition comprises 4,4,4-trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzoazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide, or a pharmaceutically acceptable salt or hydrate thereof, and a pharmaceutically acceptable carrier. The present invention also provides pharmaceutical compositions comprising 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide, or a pharmaceutically acceptable salt or hydrate thereof with a pharmaceutically acceptable carrier and optionally one or more other therapeutic agents.

The compound of the present invention is capable of reaction with a number of inorganic and organic acids to form pharmaceutically acceptable acid addition salts. Such pharmaceutically acceptable salts and common methodology for preparing them are well known in the art. See, e.g., P. Stahl, et al., HANDBOOK OF PHARMACEUTICAL SALTS: PROPERTIES, SELECTION AND USE, (VCHNWiley-VCH, 2002); S. M. Berge, et al., “Pharmaceutical Salts,” Journal of Pharmaceutical Sciences, Vol. 66, No. 1, January 1977.

Compound 1, or a pharmaceutically acceptable salt or hydrate thereof, may be prepared by a variety of procedures known in the art, as well as those described in WO2013/016081. The specific synthetic steps may be combined in different ways to prepare Compound 1, or a pharmaceutically acceptable salt or hydrate thereof.

The compounds employed as initial starting materials in the synthesis of the compound of the present invention are well known and, to the extent not commercially available, are readily synthesized using specific references provided, by standard procedures commonly employed by those of ordinary skill in the art, or are found in general reference texts.

Examples of known procedures and methods include those described in general reference texts such as Comprehensive Organic Transformations, VCH Publishers Inc, 1989; Compendium of Organic Synthetic Methods, Volumes 1-10, 1974-2002, Wiley Interscience; Advanced Organic Chemistry, Reactions Mechanisms, and Structure, 5^(th) Edition, Michael B. Smith and Jerry March, Wiley Interscience, 2001; Advanced Organic Chemistry, 4 Edition, Part B, Reactions and Synthesis, Francis A Carey and Richard J. Sundberg, Kluwer Academic/Plenum Publishers, 2000, etc., and references cited therein.

Diagnosis of cancerous malignancies by biopsy, immunophenotyping and other tests are known and routinely used. In addition to high resolution chromosome banding and advanced chromosomal imaging technologies, chromosome aberrations in suspected cases of cancer can be determined through cytogenetic analysis such as fluorescence in situ hybridization (FISH), karyotyping, spectral karyotyping (SKY), multiplex FISH (M-FISH), comparative genomic hybridization (CGH), single nucleotide polymorphism arrays (SNP Chips) and other diagnostic and analysis tests known and used by those skilled in the art.

PET/CT imaging of cancer with combined positron emission tomography (PET) and X-ray computerized tomography (CT) scanners has become a standard component of diagnosis and staging in oncology. The use of the radiolabeled tracer 2-deoxy-2-[¹⁸F]fluoro-D-glucose (FDG) is used for the majority of all PET/CT imaging procedures. One of the advantages of PET/CT imaging is its ability to detect, very early during treatment, significant changes in glucose metabolism or even complete shutoff of the neoplastic cell metabolism as a surrogate of tumor chemosensitivity assessment. In addition to cancer detection and staging, PET/CT imaging is becoming increasingly important as a quantitative monitor of individual response to therapy and an evaluation tool for new drug therapies. Changes in FDG accumulation have been shown to be useful as an imaging marker for assessing response to therapy. RECIST criteria, where response of tumors to therapy has traditionally assessed by measurement of changes in size/dimension of the tumors in CT images may not evidence early response to the therapy. Changes in size of tumors as a result of therapy may take a long period of time to develop. The most widely used parameter is the standardized uptake value (SUV) is defined as the maximal SUV value (SUVmwx) in the region of interest and reduction in SUVmx is generally considered the most reliable indicator of the metabolic activity shutdown.

The oncogenic role of Notch was first reported in human T-cell leukemia involving a translocation of the Notch1 intracellular domain to the T-cell receptor-promoter region, resulting in the over expression of Notch1 intracellular domain (Grabher et al. Nature Review Cancer, 2006(6):347-359; Weng et al. Science. 2004(306):269-271). Over expression of Notch1 intracellular domain in hematopoietic progenitor cells of mice caused the mice to exhibit T-cell acute lymphoblastic leukemia similar to humans. In addition to T-cell acute lymphoblastic leukemia, there is increasing evidence that Notch signals are oncogenic in

other cancers through multiple mechanisms including acute lymphoblastic leukemia, acute myelogenous leukemia, chronic myelogenous leukemia and erythroleukemia.

As noted above, peripheral T-cell lymphoma (non-Hodgkin lymphoma) is a solid tumor cancer of the lymphatic system that develops from mature T-lymphocytes (T-cells). This is in contrast to leukemia, T-cell acute lymphoblastic leukemia, acute lymphoblastic leukemia, acute myelogenous leukemia, chronic myelogenous leukemia, and erythroleukemia that are all cancers of immature blood-forming cells. Leukemia starts in the bone marrow and the cancerous cells spread from there into the bloodstream and to other parts of the body. The leukemia is described as lymphoid or myeloid, depending on which progenitor blood-forming cell in the maturation cascade the leukemia cells develop from.

Aberrant constitutive Notch signaling is also implicated in a number of solid tumor malignancies including breast cancer, ovarian cancer (Park et al. Cancer Research. 2006(66):6312-6318), melanoma (Gast et al. Genes. Chromosomes& Cancer. 2010(49):733-745), lung cancer, non-small cell lung cancer (Westhoff et al. PNAS, 2009(106):22293-22298), pancreatic cancer, glioblastoma, colorectal cancer, head and neck cancer, cervical cancer, prostate cancer, liver cancer, squamous cell carcinoma (oral), skin cancer and medulloblastoma (Ranganathan et al., Nature Review Cancer. 2011(11):338-351 and Supplementary Information SI (table)). Aberrant Notch signaling may be activated in particular soft tissue sarcomas Guijarro et al. Am J Pathol, 2013(182(6)):2015-2027.

Inhibition of Notch signaling presents an attractive target to provide therapeutic benefits to cancer patients whose disease was induced, maintained and progressed, or exacerbated by aberrant activation of the constitutive Notch signaling pathway. Shih et al. Cancer Research. 2007(67)1879-1882.

Ex Vivo Assay

An immunohistochemistry (IHC) assay is carried out using a PT Link, a Dako Autostainer Link 48, and Leica ST5020 Linear Stainer to analyze Notch 1, 2, and 3 intracellular domains (NIICD, N2ICD, and N3ICD, respectively) expression by an Antibody Panel Method in human tumor samples.

TABLE I Catalogue/ Composition and Reagent Name Source Identification Concentration EnVision ™ Dako K8009/SM805 Ready to Use FLEX + Rabbit (LINKER) EnVision ™ Dako K8000/SM802 Dextran coupled with FLEX/HRP peroxidase molecules and goat secondary antibody molecules against rabbit and mouse immunoglobulins. Ready to Use EnVision ™ Dako K8000/SM80 I Phosphate buffer FLEX containing hydrogen Peroxidase - peroxide, 15 mmol/L Blocking NaN3 and detergent. Reagent Ready to Use EnVision ™ Dako K8000/SM803 Buffered solution FLEX Substrate containing hydrogen Buffer peroxide and preservative. Ready to Use EnVision ™ Dako K8000/SM827 3,3′-diaminobenzidine FLEX DAB + tetrahydrochloride in Chromogen organic solvent. Ready to Use EnVision ™ Dako K8007/DM831 Tris-buffered saline FLEX Wash solution containing Buffer (20x) Tween ® 20, pH 7.6 (±0.1); 20x concentration; diluted to a Ix use concentration with Milli-Q ® DI (deionized) water (EMD Millipore). Dako Antibody Dako S0809 Tris-HCl buffer Diluent containing stabilizing protein and 0.015 mol/L sodium azide. Ready to Use EnVision ™ Dako K8000/DM828 Citrate buffer, FLEX Target pH 9.0; 50x Retrieval concentration; Solution, diluted to a Ix use High pH (50x) concentration with Milli-Q ® water (EMD Millipore), pH 8.9-9.1. FLEX Rabbit Dako Catalogue Immunoglobulin Negative Control, only: IR600 fraction of serum Ready-to-Use from non-immunized rabbits, solid phase absorbed. Ready to Use EnVision ™ Dako K8008/SM806 Modified Mayer's FLEX Hematoxylin Hematoxylin. Ready to Use

Patient tumor specimens are collected by techniques known and routinely used by those skilled in the art. The specimens are formalin-fixed, paraffin embedded (FFPE) biospecimens (blocks and/or slides), prepared at the time of collection.

Each of Notch I ICD antibody, Notch 2 ICD antibody, and Notch 3 ICD antibody, used in this assay are from proprietary hybridomas created in rabbits using human antigens from the respective cleavage site. Suitable Notch I ICD, Notch 2 ICD, and Notch 3 ICD antibodies against human forms of each Notch ICD are commercially available from various entities (Biocompare; The Buyer's Guide for Life Sciences). A suitable immunohistochemistry assay for detecting Notch 1, 2, and 3 intracellular domains (ICD) expression in human tissue samples may be prepared using the commercially available antibodies.

The full length amino acid sequence for human Notch I preprotein is found at the National Center for Biotechnology Information (NCBI) Reference Sequence: NP_060087.3; human Notch 2 preprotein, NCBI Reference sequence: AAA36377.2; and human Notch 3 preprotein, NCBI Reference Sequence: NP_000426.2. The Notch I ICD amino acid sequence is found at UniProt, reference P46531 (neurogenic locus notch homolog protein I); Notch 2 ICD amino acid sequence is found at UniProt, reference Q04721 (neurogenic locus notch homolog protein 2); and Notch 3 ICD amino acid sequence is found at UniProt, reference Q9UM47 (neurogenic locus notch homolog protein 3).

The Notch I ICD antibody is a monoclonal rabbit antibody that binds to the gamma-secretase cleaved human Notch I intracellular domain, Val 1754 through 2555, reactome.org identifier: R-HSA-157634. The Notch 2 ICD antibody is a monoclonal rabbit antibody that binds to the gamma-secretase cleaved human Notch 2 intracellular domain, Val 1697-2471, reactome.org identifier: R-HSA-157942. The Notch 3 ICD antibody is a monoclonal rabbit antibody that binds to the gamma-secretase cleaved human Notch 3 intracellular domain, Val 1662-2321, reactome.org identifier: R-HSA-157647. The Notch I ICD antibody working concentration of 1.5 μg/ml is prepared by admixing with Dako Antibody Diluent (Dako; S0809. For each of Notch 2 ICD antibody and Notch 3 ICD antibody, a working concentration of 2.0 μg/ml is prepared by admixing with Dako Antibody Diluent (Dako; S0809).

A Ix wash buffer solution is prepared by admixing EnVision™ FLEX Wash Buffer (Dako catalogue K8007, ID number DM83 1) and Milli-Q® DI (deionized) water (EMD Millipore).

A Ix target retrieval solution, high pH, is prepared by admixing Milli-Q® water (EMD Millipore) and EnVision™ FLEX Target Retrieval Solution, high pH (Dako catalogue K8000, ID number DM828) to afford a solution of pH 8.9-9.1. A substrate working solution is prepared by admixing EnVision™ Flex substrate buffer (Dako, catalogue number K8000, ID number SM803) and 1 (one) drop of EnVision™ FLEX DAB+Chromagen (Dako, catalogue number K8000, ID number SM827) per mL of EnVision™ Flex substrate buffer.

An appropriate volume of FLEX Rabbit negative control, ready to use reagent (Dako, catalogue number IR600) is used.

Unstained slides are prepared, if not provided in useable form, from FFPE block biospecimens. Appropriate reagents and slides are loaded in the Dako PT Link and then the Dako Autostainer Link 48 following the manufacturer's instructions for each. Results from this assay are provided below in Table 2.

TABLE 2 Slide Diagnosis Identification Stain Results 1 AITL AITLl-1 Notch 1 Positive 2 AITL AITLl-2 Notch 2 Negative 3 AITL AITLl-3 Notch 3 Negative 4 AITL AITLl-4 Negative Negative Control 5 AITL AITL2-l Notch 1 Positive 6 AITL AITL2-2 Notch 2 Negative 7 AITL AITL2-3 Notch 3 Negative 8 AITL AITL2-4 Negative Negative Control 9 AITL AITL3-l Notch 1 Positive 10 AITL AITL3-2 Notch 2 Negative 11 AITL AITL3-3 Notch 3 Negative 12 AITL AITL3-4 Negative Negative Control 13 AITL AITL4-l Notch 1 Positive 14 AITL AITL4-2 Notch 2 Negative 15 AITL AITL4-3 Notch 3 Negative 16 AITL AITL4-4 Negative Negative Control 17 AITL AITLS-1 Notch 1 Positive 18 AITL AITLS-2 Notch 2 Negative 19 AITL AITLS-3 Notch 3 Negative 20 AITL AITLS-4 Negative Negative Control 21 AITL AITL6-l Notch 1 Positive 22 AITL AITL6-2 Notch 2 Negative 23 AITL AITL6-3 Notch 3 Negative 24 AITL AITL6-4 Negative Negative Control 25 AITL AITL7-l Notch 1 Positive 26 AITL AITL7-2 Notch 2 Negative 27 AITL AITL7-3 Notch 3 Negative 28 AITL AITL7-4 Negative Negative Control 29 AITL AITL8-l Notch 1 Positive 30 AITL AITL8-2 Notch 2 Negative 31 AITL AITL8-3 Notch 3 Negative 32 AITL AITL8-4 Negative Negative Control 33 AITL AITL9-l Notch 1 Positive 34 AITL AITL9-2 Notch 2 Negative 35 AITL AITL9-3 Notch 3 Negative 36 AITL AITL9-4 Negative Negative Control 37 AITL AITLl0-1 Notch 1 Positive 38 AITL AITLl0-2 Notch 2 Negative 39 AITL AITLl0-3 Notch 3 Negative 40 AITL AITLl0-4 Negative Negative Control 41 AITL AITLll-1 Notch 1 Positive 42 AITL AITLll-2 Notch 2 Negative 43 AITL AITLll-3 Notch 3 Negative 44 AITL AITLl 1-4 Negative Negative Control Positive Control Notch 1 Positive Positive Control Notch 2 Positive Positive Control Notch 3 Positive 45 AITL AITL12-l Notch 1 Positive 46 AITL AITL12-2 Notch 2 Negative 47 AITL AITL12-3 Notch 3 Negative 48 AITL AITL12-4 Negative Negative Control 49 AITL AITL13-l Notch 1 Positive 50 AITL AITL13-2 Notch 2 Negative 51 AITL AITL13-3 Notch 3 Negative 52 AITL AITL13-4 Negative Negative Control 53 AITL AITL14-l Notch 1 Positive 54 AITL AITL14-2 Notch 2 Negative 55 AITL AITL14-3 Notch 3 Negative 56 AITL AITL14-4 Negative Negative Control 57 AITL AITL15-l Notch 1 Positive 58 AITL AITL15-2 Notch 2 Negative 59 AITL AITL15-3 Notch 3 Negative 60 AITL AITL15-4 Negative Negative Control 61 AITL AITL16-l Notch 1 Positive 62 AITL AITL16-2 Notch 2 Negative 63 AITL AITL16-3 Notch 3 Negative 64 AITL AITL16-4 Negative Negative Control 65 AITL AITL17-l Notch 1 Negative 66 AITL AITL17-2 Notch 2 Negative 67 AITL AITL17-3 Notch 3 Negative 68 AITL AITL17-4 Negative Negative Control 69 AITL AITL18-l Notch 1 Positive 70 AITL AITL18-2 Notch 2 Negative 71 AITL AITL18-3 Notch 3 Negative 72 AITL AITL18-4 Negative Negative Control 73 AITL AITL19-l Notch 1 Positive 74 AITL AITL19-2 Notch 2 Negative 75 AITL AITL19-3 Notch 3 Negative 76 AITL AITL19-4 Negative Negative Control 77 AITL TLN14-007-007 Notch 1 Positive 78 AITL TLNl 4-007-008 Notch 2 Negative 79 AITL TLN14-007-009 Notch 3 Negative 80 AITL TLN14-007-010 Negative Negative Control Positive Control Notch 1 Positive Positive Control Notch 2 Positive Positive Control Notch 3 Positive

The data in Table 2 shows Notch 1 ICD, and as a consequence, Notch pathway signaling, is upregulated in AITL human patient tumor samples in this assay. These data, from this assay, suggest a Notch 1 pathway signaling inhibitor, such as 4,4,4-Trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide, or a pharmaceutically acceptable salt or hydrate thereof, will demonstrate efficacy against aggressive PTCL tumors.

Clinical Evaluation

A study of 4,4,4-Trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate in patients with advanced or metastatic cancer.

Study Design

This study is a multicenter, nonrandomized, open-label, dose-escalation study followed by cohort expansion of oral dosed 4,4,4-trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate in outpatients with advanced or metastatic cancer.

Study Objectives

The primary objective of this study is to determine a recommended Phase 2 dose of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate that may be safely administered to patients with advanced or metastatic cancer. The primary objective is to confirm the recommended Phase 2 dose of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate that may be safely administered to patients with specific tumor types and to document antitumor activity.

The secondary objectives of the study are to characterize the safety and toxicity profile of 4,4,4-trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanami de hydrate as assessed by National Cancer Institute's (NCI) Common Terminology Criteria for Adverse Events (CTCAE) v 4.0; to estimate the pharmacokinetic (PK) parameters of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate; to document any antitumor activity observed with 4,4,4-trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate; and to assess duration of response, progression-free survival (PFS), and overall survival (OS).

Exploratory objectives are to explore renal clearance and PK metabolites of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate in plasma and urine; explore predictive biomarkers related to 4,4,4-trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate; explore pharmacodynamic (PD) effects of 4,4,4-trifluoro-N-[(S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate on biomarkers indicative of Notch activity (Notch intracellular domain by immunohistochemistry or an alternative validated method) including cytokeratin 18 or Rules Based Medicine; explore the utility of positron emission tomography (PET) scan or PET/computed tomography (CT), PET/CT, to assess treatment effect with 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate; and to explore the utility of dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) to assess treatment effect with 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate.

Study Design

Cohort expansion of oral 4,4,4-trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate in outpatients with advanced or metastatic cancer. Patients will be entered based on screened molecular alterations related to the Notch pathway. Patients initially dosed with 75 mg/dose administered T.I.W. are dose-reduced to 50 mg/dose administered T.I.W.

Trial Drug

4,4,4-Trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate, given orally as capsules 3 times per week during a 28-day cycle.

4,4,4-Trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate will be supplied as 25 and 50 mg capsules in bottles for oral consumption. These capsules should be stored at room temperature within the temperature range stated on the label.

Planned Duration of Treatment

Patients will receive 2 cycles (28 days each) of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate unless one or more of the criteria for discontinuation are fulfilled. A patient may receive more than 2 cycles of treatment only if: 1) none of the criteria for discontinuation have been fulfilled, and 2) the investigator determines that the patient is experiencing clinical benefit from the treatment.

The planned duration is not fixed; patients will remain on study until they fulfill one (1) of the criteria for study discontinuation. The post-discontinuation follow-up period begins the day after the patient and the investigator agree that the patient will no longer continue study treatment and is defined by the following periods:

The short term follow-up period begins 1 day after discontinuation of study treatment and lasts approximately 30 days.

The long-term follow-up period begins 1 day after the short-term follow-up period is completed and continues until death or study closure to collect survival data.

After discontinuation, tumor measurements and other study procedures will be performed.

This study will be considered closed approximately 12 months from the date that the last patient was enrolled. Patients who are benefitting from treatment may continue to receive study drug for long-term durations, even after the study has closed and final database lock has occurred in the continued access period.

Dosing

4,4,4-Trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanami de hydrate will be administered orally TIW following one of the following schedules (decision at investigator's discretion):

4,4,4-Trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanami de hydrate will be administered orally TIW following I of these schedules (decision at investigator's discretion):

-   -   Monday, Wednesday, Friday every week for a 28-day cycle;     -   Tuesday, Thursday, Saturday every week for a 28-day cycle;     -   Wednesday, Friday, Sunday every week for a 28-day cycle;     -   Thursday, Saturday, Monday every week for a 28-day cycle.

Criteria for Evaluation

Safety: NCI CTCAE, version 4.0, adverse events (AE) and dose-limiting toxicities (DLT); collection of blood and urine samples for standard laboratory tests, including chemistry, hematology, coagulation, and urinalysis.

Bioanalytical (including PK and PD): Plasma concentrations of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethy1]butanamide hydrate.

Efficacy: Efficacy will be assessed using Response Evaluation Criteria in Solid Tumors (RECIST) v1.1 or using the Cheson et al., J Clin. Oneal., 2007, 25(5): 579-586, response criteria for lymphoma. Each patient will be assessed by I or more of the following radiologic tests for tumor measurement: X-ray computerized tomography (CT) scan; magnetic resonance imaging (MRI); chest X-ray; positron emission tomography (PET) scan; dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI); PET/CT imaging Standardized Uptake Values(SUVMAX); Dynamic Contrast-Enhanced Ultrasonography (DCE-US).

Each patient's full extent of disease will also be assessed with: applicable tumor measurement by RECIST 1.1 (Eisenhauer et al., Eur J Cancer. 2009, 45(2): 228-247); Cheson et al., J Clin. Oneal., 2007, 25(5): 579-586; and Choi et al., J Clin Oneal. 2007, 25(13): 1753-1759; and evaluation of performance status by ECOG, Oken et al., Am J Clin Oneal. 1982, 5: 649-655. To confirm objective responses, all lesions should be radiologically assessed, and the same radiologic method used for the initial response determination should be repeated at least 4 weeks following the initial observation of an objective response, using the sample method that was used at baseline. Partial metabolic response by PET scan is defined as a minimum of 15±25% in tumor [18F]-FDG SUV after one cycle of therapy, and greater than 25% after more than one treatment cycle and should be confirmed at least 4 weeks later, according to PET response criteria of the European Organization for Research and Treatment of Cancer (Young et al., Eur J Cancer. 1999, Dec., 35(13): 1773-82.

Statistical Methods

Safety: Dose escalation will be driven by safety using the 3+3 method. Model-based analyses that incorporate prior expectations about the dose-toxicity curve will be fitted to the data at the end of each cohort, which will be used by investigators and Lilly clinical research physician to determine the next dose level. The maximum tolerated dose is defined as the highest tested dose that has less than 33% probability of causing a DLT during Cycle 1.

Efficacy: Tumor response data will be tabulated and summarized by study part.

Pharmackintic: PK parameters for 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate will be analyzed by standard non-compartmental methods of analysis.

Pharmacodynamics: All PD data will be assessed. Exploratory PK/PD analyses may be conducted to identify the exposure-biomarker response relationship.

Exploratory Samples:

Blood samples will be collected for exploratory analysis of circulating Amyloid beta (A) peptides before and after treatment.

Where local regulations allow, a blood sample will be collected for pharmacogenetic (PGx) analysis. It is a I-time collection.

Samples will be stored and exploratory analysis may be performed to identify genetic variants that might play a role in tumor biology or to evaluate their association with observed clinical outcomes to 4,4,4-trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide. These investigations may be limited to a focused candidate gene study or, if appropriate, genome wide association studies may be performed to identify regions of the genome associated with the variability observed in drug response. Samples will only be used for investigations related to disease and drug or class of drugs under study in the context of this clinical program. They will not be used for broad exploratory unspecified disease or population genetic analysis.

In the event of an unexpected AE or the observation of unusual response, the samples may be genotyped and analysis may be performed to evaluate a genetic association with response to

A mandatory tumor tissue sample and a skin punch sample obtained previously, within two years of the date of enrollment, or a fresh sample if no archival sample can be located for measuring various biomarkers, potentially including gene-expression profiling as well as other exploratory biomarkers. Pre- and post-dose tumor and skin biopsies will also be collected for analysis.

Preliminary data on 3 patients having relapsed or refractory peripheral T-Cell lymphoma (two with AITL and one with PTCL-NOS administered 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide hydrate in cycle 1 of an ongoing clinical trial are presented in Table 3.

TABLE 3 CT Scan PET Other Patient Tumor type assessment Scan assessments 1 AITL Tumor decrease Partial of80% response 2 AITL Tumor decrease — of20% 3 PTCL-NOS Stable Decrease of Abnormal T cells and hematological recovery of platelets 

We claim:
 1. A method of treating a patient suffering from aggressive peripheral T-cell lymphoma (PTCL), comprising administering to a PTCL not otherwise specified (PTCL-NOS), anaplastic large-cell lymphoma (ALCL), or angioimmunoblastic T-cell lymphoma (AITL) patient in need of treatment an effective amount of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide, or a pharmaceutically acceptable salt or hydrate thereof, wherein the administering comprises: administering a loading dose of 75 to 150 mg/dose of 4,4,4-trifluoro-N-[(1 S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide or a pharmaceutically acceptable salt or hydrate thereof; followed by administering a maintenance dose of 25 to 75 mg/dose of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide or a pharmaceutically acceptable salt or hydrate thereof.
 2. The method of claim 1, wherein the loading dose is administered two or three times per week for at least one week of a 28 day cycle.
 3. The method of claim 1, wherein the loading dose of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide or a pharmaceutically acceptable salt or hydrate thereof is administered every other day over a five day period followed by two days without administration (T.I.W.).
 4. The method of claim 1, wherein the maintenance dose is administered three times per week.
 5. The method of claim 1, wherein the maintenance dose of 4,4,4-trifluoro-N-[(1S)-2-[[(7S)-5-(2-hydroxyethyl)-6-oxo-7H-pyrido[2,3-d][3]benzazepin-7-yl]amino]-1-methyl-2-oxo-ethyl]butanamide or a pharmaceutically acceptable salt or hydrate thereof is administered T.I.W.
 6. The method of claim 1, wherein 2 or 3 loading doses are administered over the course of one week, or 4 to 6 loading doses are administered over the course of two weeks.
 7. The method of claim 1, wherein 8 to 12 loading doses are administered over the course of four weeks.
 8. The method of claim 1, wherein the loading dose is 75 mg/dose.
 9. The method of claim 1, wherein the maintenance dose is 50 mg/dose.
 10. The method of claim 1, wherein the loading dose is 75 mg/dose and the maintenance dose is 50 mg/dose.
 11. The method of claim 1, wherein the amounts of the loading dose and the maintenance dose are different.
 12. The method of claim 1, wherein the patient has advanced or metastatic PTCL-NOS, ALCL, or AITL.
 13. The method of claim 1, wherein the maintenance dose is administered over any remaining days of the 28 day cycle.
 14. The method of claim 13, wherein, after the maintenance dose is administered over any remaining days of the 28 day cycle, the maintenance dose is administered over one or more additional 28 day cycles.
 15. The method of claim 1, further comprising administering 1 to 50 mg/dose of a corticosteroid during administration of the loading dose.
 16. The method of claim 15, wherein the corticosteroid is selected from the group consisting of hydrocortisone, hydrocortisone acetate, cortisone acetate, tixocortol pivalate, prednisone, methylprednisolone, and dexamethasone.
 17. The method of claim 15, wherein: 2 or 3 loading doses are administered over the course of one week; 4 to 6 loading doses are administered over the course of two weeks; or 8 to 12 loading doses are administered over the course of four weeks; and/or the maintenance dose is administered three times per week.
 18. The method of claim 1, wherein: 2 or 3 loading doses are administered over the course of one week; or 4 to 6 loading doses are administered over the course of two weeks; or 8 to 12 loading doses are administered over the course of four weeks; and the maintenance dose is administered three times per week.
 19. The method of claim 18, further comprising administering 1 to 50 mg/dose of a corticosteroid during administration of the loading dose.
 20. The method of claim 19, wherein the corticosteroid is selected from the group consisting of hydrocortisone, hydrocortisone acetate, cortisone acetate, tixocortol pivalate, prednisone, methylprednisolone, and dexamethasone. 